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Prevention and Management of Surgical Wound Complications

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Prevention and Management of Surgical Wound Complications Foundations of Best Practice for Skin and Wound Management BEST PRACTICE RECOMMENDATIONS FOR THE Prevention and Management of Surgical Wound Complications Connie L. Harris RN MSc ET IIWCC Janet Kuhnke RN BA BScN MSc ET Jennifer Haley BMSc MSC Karen Cross MD PhD FRCSC Ranjani Somayaji BScPT MD FRCPC Jessica Dubois LIT BAH MLIS(c) Richard Bishop RN BScN MN IIWCC Kerstin Lewis RN BSN IIWCC The best practice recommendation articles are special publications of Wound Care Canada. Together they form the Foundations of Best Practice for Skin and Wound Management, an online resource available for free download from the Wounds Canada website (woundscanada.ca). These 2017 updates build on the work of previous author teams and incorporate the latest research and expert opinion. We would like to thank everyone involved in the production of past and present versions of these articles for their hard work, diligence and rigour in researching, writing and producing these valuable resources. Executive Editor: Sue Rosenthal Project Editor: Heather L. Orsted Editorial Assistant: Katie Bassett Copy Editor: Allyson Latta Art Direction and Layout: Robert Ketchen Photo Researcher: Joanne Crone This paper was produced by the Canadian Association of Wound Care (Wounds Canada). The editing and layout were supported by an unrestricted educational grant from Smith & Nephew. woundscanada.ca [email protected] © 2017 Canadian Association of Wound Care All rights reserved. 1534r1E Last updated 2017 02 27. Foundations of Best Practice for Skin and Wound Management BEST PRACTICE RECOMMENDATIONS FOR THE Prevention and Management of Surgical Wound Complications Connie L. Harris RN MSc ET IIWCC Janet Kuhnke RN BA BScN MSc ET Jennifer Haley BMSc MSC Karen Cross MD PhD FRCSC Ranjani Somayaji BScPT MD FRCPC Jessica Dubois LIT BAH MLIS(c) Richard Bishop RN BScN MN IIWCC Kerstin Lewis RN BSN IIWCC Introduction Introduction The Canadian Patient Safety Institute has identified the safety of surgical care as one of its four priority areas.1 According to the Organization for Economic Co-operation and Development, 378,448 surgical procedures were performed in Canada in 2013.2 Surgical procedures can be performed either as inpatient, day surgery with admis- sion of at least one night or, depending on the procedure, in outpatient ambulatory care settings. The final step in the surgical procedure is to close the surgical incision (wound). Many surgical procedures are complex and may carry significant risks for patients regardless of the health-care setting.3 The patient facing surgery brings their own unique individual health history. Some bring excellent health with the expecta- tion of rapid healing, while others have surgery when their complex health history/ issues seriously impair their general recovery and wound healing.4 Seventy-seven percent of surgical patient deaths are reported to be related to infec- tion.5 Infection has a direct correlation to open surgical wounds. Surgical site infection (SSI) is the most common health-care-associated infection among surgical patients. The Centers for Disease Control in the United States reported that while advances have been made in infection control practices, including improved operating room ventilation, sterilization methods, barriers, surgical technique and availability of antimi- crobial prophylaxis, SSI remains a substantial cause of morbidity, prolonged hospitali- zation and death.6 Therefore, recognition of the potential for surgical wound infection may be the most important issue to address when discharge planning for a post-surgi- cal patient.7 In addition, it is estimated that 75% of surgical procedures are performed Foundations of Best Practice for Skin and Wound Management | Best Practice Recommendations for the Prevention and Management of Surgical Wound Complications | 5 on outpatients, making the issues of prevention, detection, treatment and reporting of SSIs in the community or long-term-care sectors essential. For patients who develop an SSI, increased hospital length of stay (LOS) is approximately seven to eight days, while urinary tract infections increase LOS by one to four days, bloodstream infections increase LOS by seven to 30 days and pneumonia increases LOS for seven to 30 days.8 SSIs are of growing concern to the health-care system. SSIs account for 16% of all health-care-associated infections; of these, 1% related to orthopedic procedures and 10% to large bowel surgery. SSIs can often be prevented through initiatives focused on pre-, intra- and post-operative care and education.9,10 The Wound Prevention and Management Cycle This paper offers a practical, easy-to-follow guide incorporating the best available evi- dence that outlines a process, or series of consecutive steps, that supports patient-cen- tred care. This process, called the Wound Prevention and Management Cycle (see Figure 1) guides the clinician through a logical and systematic method for developing a customized plan for the prevention and management of wounds from the initial assessment to a sustainable plan targeting self-management for the patient. 6 | Best Practice Recommendations for the Prevention and Management of Surgical Wound Complications | Foundations of Best Practice for Skin and Wound Management The Wound Prevention and Management Cycle FigureAssess/Reassess 1: The Wound PreventionSet Goals and ManagementAssemble Cycle Team Establish and ImplementEvaluate DOMAIN OF C THE ARE 1 Assess and/or Reassess 2 Set Goals • Assess the patient, the wound (if applicable), as well as environmental and system challenges. • prevention • healing • quality of life and • Identify risk and causative factors that may • non-healing symptom control impact skin integrity and wound healing. • non-healable 5 Evaluate Outcomes Goals Met: Goals Partially Met 3 Assemble the Team • Ensure sustainability. or Not Met: • Select membership based on patient need. Cycle is completed • reassess 4 Establish and Implement a Plan of Care • Establish and implement a plan of care that addresses: • the environment and system • the patient • the wound (if applicable) • Ensure meaningful communication among all members of the team. • Ensure consistent and sustainable implementation of the plan of care. Provide Local Skin/Wound Care (if applicable) Cleansing/ Bacterial Moisture debridement: balance: balance: • Remove debris • Rule out or treat • Ensure adequate and necrotic or superficial/ hydration. indolent tissue, spreading/ if healable. systemic infection. Select appropriate dressing and/or advanced therapy © 2016 CAWC · All rights reserved. The recommendations in this document are based on the best available evidence and © 2016 CAWC · Printed in Canada · v07 · 378E are intended to support the clinician, the patient, his/her family and the health-care team in planning and delivering the best clinical practice. Two foundational papers supplement this document with additional evidence-informed information and rec- Foundations of Best Practice for Skin and Wound Management | Best Practice Recommendations for the Prevention and Management of Surgical Wound Complications | 7 ommendations that are general to all wound types: “Skin: Anatomy, Physiology and Wound Healing,”11 and “Best Practice Recommendations for the Prevention and Man- agement of Wounds.”12 There are three guiding principles within the best practice recommendations (BPRs) that support effective prevention and management of skin breakdown: 1. the use of the Wound Prevention and Management Cycle regardless of the specifics to prevent and manage skin breakdown 2. the constant, accurate and multidirectional flow of meaningful information within the team and across care settings 3. the patient as the core of all decision making Quick Reference Guide The quick reference guide (QRG) (see Table 1) provides the recommendations associ- ated with the five steps in the Wound Prevention and Management Cycle (see Figure 1). These recommendations are discussed with the supporting evidence. Table 1: Wound Prevention and Management Quick Reference Guide Step Recommendation Evidence 1 Assess and/ 1.1 Select and use validated patient assessment tools. RNAO Ia or Reassess 1.2 Identify risk and causative factors that may impact skin integrity and NICE 2/ wound healing. RNAO I–IV 1.2.1 Patient: Physical, emotional and lifestyle 1.2.2 Environmental: Socio-economic, care setting, potential for self- management 1.2.3 Systems: Health-care support and communication 1.3 Complete a wound assessment, if applicable. RNAO IV 2 Set Goals 2.1 Set goals for prevention, healing, non-healing and non-healable wounds. RNAO IV 2.1.1 Identify goals based on prevention or healability of wounds. 2.1.2 Identify quality-of-life and symptom-control goals. 3 Assemble 3.1 Identify appropriate health-care professionals and service providers. NICE 4/RNAO IV the Team 3.2 Enlist the patient and their family and caregivers as part of the team. RNAO IV 3.3 Ensure organizational and system support. RNAO IV 4 Establish 4.1 Identify and implement an evidence-informed plan to correct the causes NICE 2+/RNAO IV and or co-factors that affect skin integrity, including patient needs (physical, Implement emotional and social), the wound (if applicable) and environmental/ a Plan of system challenges. RNAO Ia-III Care 4.2 Optimize the local wound environment aided through 4.2.1 Cleansing 4.2.2 Debriding 4.2.3 Managing bacterial balance 4.2.4 Managing moisture balance RNAO Ia-IV 4.3 Select the appropriate dressings and/or advanced therapy. NICE 4/RNAO
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